ADHD Diagnosis

15 disorders of childhood and adolescence (neurodevelopmental disorders)

learning objectives 15

·  15.1 How does maladaptive behavior appear in different life periods?

·  15.2 What are the common disorders of childhood?

·  15.3 Do anxiety and depression appear in children and adolescents?

·  15.4 What are some specific disorders that occur in childhood?

·  15.5 What are intellectual disabilities?

·  15.6 How can we plan better programs to help children and adolescents?

A Case of Adolescent Depression and Attempted Suicide Emily is 15-year-old girl from a middle-class Caucasian background who had a history of depression during her childhood. She had periods of low mood, poor self-esteem, and social withdrawal. She also had symptoms of anxiety and was very reluctant to leave her home. During her year in the seventh grade, she became so fearful of going to school that she missed so many days she had to repeat the grade. She currently is in the eighth grade and has, to this point, missed a great deal of school. Her family became very concerned over Emily’s low mood and isolation, so they enrolled her in an out-patient treatment program for depression, anxiety episodes, and eating disorders. Her depression continued, and she became more isolated, lonely, and depressed and would not leave her room even for meals. One day her grandmother found her in their car in the garage with the engine running in an effort to end her life. Emily was admitted into an inpatient treatment program following her serious suicide attempt.

There is a history of psychiatric problems, particularly mood disorders, in her family. Her mother has been hospitalized on three occasions for depression. Her maternal grandfather, now deceased, was hospitalized at one time following a manic depressive episode.

In the early phases of her hospitalization, Emily underwent an extensive psychological and psychiatric evaluation. She was administered a battery of tests, including the Minnesota Multiphasic Personality Inventory for Adolescents (MMPI-A). She was cooperative with the evaluation and provided the assessment staff with sufficient information regarding her mood and attitudes to assist in developing a treatment program.

Emily showed many symptoms of a mood disorder in which both depression and anxiety were prominent features. The psychological evaluation indicated that she was depressed, anxious, and felt unable to deal with the school stress that her condition prompted. Moreover, her physical appearance and eating behavior suggested the strong likelihood of anorexia nervosa. Emily showed an extreme degree of social introversion on several measures and acknowledged her reticence at engaging in social interactions. The assessment psychologist concluded that her personality characteristics of social withdrawal, isolation, and difficult interpersonal relationships would likely result in her having problems in establishing a therapeutic relationship. Her treatment program involved supportive cognitive therapy along with antidepressant medication.

Although she endorsed a broad range of anxiety symptoms, in her testing and in the intake interview she endorsed few items regarding suicidal ideation. This was not sufficient evidence to support a conclusion that she was at less risk for suicide; however, it could simply reflect her unwillingness to openly discuss her recent attempt. Her past behavior and low mood indicated a need to consider the possibility of further suicide attempts.

She remained in inpatient treatment for 3 weeks and was discharged with the summary that she had shown substantial improvement. She was, however, referred for further psychological treatment on an outpatient basis.

Source: Adapted from Williams & Butcher,  2011 , pp. 151–63.

Until the twentieth century, little account was taken of the special characteristics of psychopathology in children; maladaptive patterns considered relatively specific to childhood, such as autism, received virtually no attention at all. Only since the advent of the mental health movement and the availability of child guidance facilities at the beginning of the twentieth century have marked strides been made in assessing, treating, and understanding the maladaptive behavior patterns of children and adolescents.

The problems of childhood were initially seen simply as downward extensions of adult-oriented diagnoses. The prevailing view was one of children as “miniature adults.” But this view failed to recognize special problems, such as those associated with the developmental changes that normally take place in childhood or adolescence. Only relatively recently have clinicians come to realize that they cannot fully understand childhood disorders without taking these developmental processes into account. Today, even though great progress has been made in providing treatment for disturbed children, facilities are still inadequate to the task, and most children with mental health problems do not receive psychological attention.

The number of children affected by psychological problems is considerable. Research studies in several countries have provided estimates of childhood disorders. Roberts, Roberts, et al. ( 2007 ) found that 17.1 percent of adolescents in large metropolitan areas of the United States meet the criteria for one or more DSM diagnoses. Verhulst ( 1995 ) conducted an evaluation of the overall prevalence of childhood disorder based on 49 studies involving over 240,000 children across many countries and found the average rate to be 12.3 percent. In most studies, maladjustment is found more commonly among boys than among girls; however, for some diagnostic problems, such as eating disorders (see  Chapter 8 ), rates are higher for girls than for boys. The most prevalent disorders are attention-deficit/hyperactivity disorder (ADHD) (Ryan-Krause et al.,  2010 ) and separation anxiety disorders (Cartwright-Hatton et al., 2006 ). Some subgroups of the population—for example, Native Americans—tend to have higher rates of mental disorders. One study reported that 23 percent of the Native American children rated in the sample met criteria for 1 of the 11 mental disorders in the survey and 9 percent met criteria for 2 or more of the disorders (Whitbeck et al.,  2006 ).

Maladaptive Behavior in Different Life Periods

Several behaviors that characterize maladjustment or emotional disturbance are relatively common in childhood. Because of the manner in which personality develops, the various steps in growth and development, and the differing stressors people face in childhood, adolescence, and adulthood, we would expect to find some differences in maladaptive behavior in these periods. The fields of developmental science (Hetherington,  1998 ) and, more specifically,  developmental psychopathology  (Kim-Cohen,  2007 ) are devoted to studying the origins and course of individual maladaptation in the context of normal growth processes.

It is important to view a child’s behavior in the context of normal childhood development (Silk et al.,  2000 ). We cannot consider a child’s behavior abnormal without determining whether the behavior in question is appropriate for the child’s age. For example, temper tantrums and eating inedible objects might be viewed as abnormal behavior at age 10 but not at age 2. Despite the somewhat distinctive characteristics of childhood disturbances at different ages, there is no sharp line of demarcation between the maladaptive behavior patterns of childhood and those of adolescence, or between those of adolescence and those of adulthood. Thus, although our focus in this chapter will be on the behavior disorders of children and adolescents, we will find some inevitable carryover into later life periods.

Varying Clinical Pictures

The clinical picture of childhood disorders tends to be distinct from the clinical picture of disorders in other life periods. Some of the emotional disturbances of childhood may be relatively short lived and less specific than those occurring in adulthood. However, some childhood disorders severely affect future development. One study found that individuals who had been hospitalized as child psychiatric patients (between the ages of 5 and 17) died early in life due to unnatural causes (about twice the rate of the general population) when followed up from 4 to 15 years later (Kuperman et al.,  1988 ). The suicide risk among some disturbed adolescents is long-lasting and requires careful follow-up and attention (Fortune et al.,  2007 ). Suicidal thoughts are not uncommon in children. Riesch and colleagues ( 2008 ) report that 18 percent of sixth graders have thoughts of killing themselves. Two other recent studies have reported rates for children under age 15. Dervic, Brent, and Oquendo ( 2008 ) report that international suicide rates are 3.1 per million. Hawton and Harriss ( 2008 ) report that the long-term risk of suicide is 1.1 percent, with girls more likely than boys to commit suicide. Both studies report that difficult family relationships are the leading cause of suicidal behavior. Being bullied by another child is another factor that has been found to be associated with risk of suicide (Rivers & Noret,  2010 ).